Ask Karen Jordan what has been wonderful in her life in the last 23 years and she can list a bunch of joys without hesitation: Her children's marriages, the birth of 11 grandchildren, her own second marriage to the man she calls "a real treasure in my life," the adventures they shared in Floridaâ€¦.

The time span is important because 23 years ago, she planned how she was going to kill herself. Looking back, she thinks she had post-partum depression. At 31, she'd just had her seventh baby, she and her husband lived in a single-wide trailer and she was more than depressed. She was sure she wasn't a good mom, that she couldn't handle the task of raising seven little people, and was positive that everyone in her life would be better off without her. But while she planned in detail how she would die, she couldn't figure out how to make sure that her children wouldn't be the ones to find her. That saved her life.

She tells the story from a distance, as if the planning and self-loathing belonged to someone else. But she remembers the despondency and her certainty that her death wouldn't matter and that it might even help those around her.

Suicide is a public health issue, but not one people are comfortable discussing. In the United States, it's the 10th or 11th leading cause of death, depending on your source. The American Foundation for Suicide Prevention (AFSP) says nearly 37,000 Americans died at their own hands in 2009, the most recent year data is available. It was the No. 4 cause of death for adults 18 to 65, No. 6 among those 5 to 14, No. 3 for those ages 15 to 24, No. 2 for those 25-34. A Centers for Disease Control and Prevention survey said nearly 1 in 7 high school students said they seriously considered suicide in 2010. While three times as many females attempt suicide, males complete the act four times as often. In 2009, CDC said more than 374,000 people were treated for self-inflicted injuries at emergency rooms nationwide.

But suicide is a tricky topic for the media to tackle. Sometimes, reporters ignore it for fear of glorifying the act, nervous they'll trigger a copycat suicide or a "cluster," as experts call a series of suicides that share some common factor that makes it likely they were related, like location or age or a group that knew each other. Increasingly, though, experts say silence kills. If it's not talked about, people who struggle don't know it's safe to ask for help or that powerful resources are available to them.

This week, KSL and the Deseret News have teamed up to focus on suicide and prevention efforts that make a difference.

Giving it voice

Sonja Baum's father attempted suicide and his brother died at his own hand. Her nephew killed himself, too, part of a rash of suicides in northern Sanpete that took at least 14 lives over the course of about a year. Another of Baum's close relatives tried to end her own life. But through all those years and sorrows, her family spoke of suicide in hushed voices or not at all, terrified they'd "trigger" another death. Not any more. "I've learned that it's okay to talk about it. We were all afraid; we thought it would promote suicide. It's already there." There, too, though, are an "army" of people who would like nothing more than to listen and help without judging â€” people who want those who are suffering, like her nephew did, to choose life.

The suicide belt

Suicide prevention is a serious undertaking in Utah, which is in the midst of the suicide "belt" that runs through the Rocky Mountains. Some experts believe that states like Alaska, Montana, Wyoming and Utah â€” western states dominate the top 10 places in the US where suicide is most common â€” have higher-than-average suicide rates because they are home to vast rural areas where families cannot as easily get mental health support.

Suicide attempts, completed or not, are most often caused by serious mental conditions like depression or bipolar disorder that have not been diagnosed or have not been effectively treated. But mental illness alone typically won't do it. There's a complicating factor, like a romantic breakup, attention deficit hyperactivity disorder or substance abuse. Recent stresses can be a trigger, particularly among impulsive youths. AFSP data says 80-90 percent of those who killed themselves were not in counseling or treatment programs at the time of their deaths.

The first step to suicide prevention is to recognize signs, including suicidal talk, obsession with death, loss of interest in formerly loved activities, mood swings, not eating, sleeping too much or too little, taking excessive risks, withdrawing, increased drug use, agitation or anxiety, buying a gun or putting affairs in order.

Underlying mental illness is typically treatable with medications and with cognitive therapy.

Baum's other relative had many of the signs, but Baum and her family were blindsided by the suicide attempt. "She withdrew, she quit going out, she quit talking to friends. I don't know if I was in denial or not being aware. Now, it seems apparent how depressed she was." If she had seen it, Baum wonders whether she'd have addressed it. The suicide attempt removed the reluctance. They had to act fast.

"I think suicide needs to be talked about," says clinical psychologist John Malouf of Valley Mental Health in Salt Lake City. "If somebody is concerned about a family member or friend, it is okay to say, 'Are you thinking about hurting yourself' and bring it out." Not everyone set on killing himself will tell you. The point is someone might and it could "open the door to exploring alternatives."

Suicide is a permanent solution to a temporary problem, Malouf said. If lethal means are available, someone who is impulsive may act. He warned that communication needs to be open, but it's also important to make sure there are no tools of self-destruction available. There's a tendency -- perhaps a yearning -- to think that threats of self harm are empty. Experts say you can't count on it. They require expert assessment and perhaps intervention.

Generation to generation

It is probably not suicide that runs in families, he said, but rather the mental health diagnosis that causes it. But there are factors that increase the risk, including earlier attempts, a close relative who committed suicide, recent losses such as a breakup or death, social isolation, substance abuse and availability of handguns and ammunition, among others.

In a youthful population, ideally parents and schools would pick up on signals and direct the individual to professional help, said Dr. Mark Schwei, medical director for Primary Children's inpatient psychiatry unit. But again, you have to discuss what's going on and what's available. If children and adults don't know about services, they don't do any good.

Schools tackle trouble

Bullying puts both the victim and the bully at higher risk of suicide. Someone who has been both the picked-on and the aggressor is at the highest risk.

The strategies to prevent bullying have a lot in common with suicide prevention, including the type of school environment, outreach to families and identification of students in need of mental and behavioral health services, according to the Utah school suicide prevention manual that Gregory A. Hudnall, Provo School District's associate superintendent, and others have written. Hudnall became an expert in suicide prevention after he was called upon as a school principal years ago to identify the body of a young man who killed himself. He became an anti-suicide activist and policymaker.

The manual discusses factors and strategies, including how to talk to kids about suicide using an age-appropriate approach.

Schwei said 77 percent of all public schools have some kind of intervention program. Some of them target enhancing "protective factors," like making sure students don't feel alone, have connections, can talk to someone.

He said research finds little evidence that education and awareness alone are effective, but paired with other approaches, like trained screeners, success skyrockets. Florida's South Elgin High School Suicide Prevention Program, for instance, is based on a "care and tell" model that has great results. Its core is teaching that suicidal thoughts are not normal, but are an emergency that must be addressed. Volunteers are eager to listen and help.

Hudnall was among those who set up "Hope Squads" in his district as part of a comprehensive prevention effort that has seen no suicides in the last six years. One of the first things they did was survey Timpview High School students, asking them in every English class to name a student they'd be willing to talk to in a crisis. Some names kept cropping up, "normal kids who were nonjudgmental and very accepting."

That was the first Utah Hope Squad. They did the same thing in middle schools and have now formed teams of caring kids in grade schools, too. Students volunteer to be buddies, to listen, to care to prevent both bullying and suicide. The effort is catching on in other Utah districts. Peer mentoring programs work, according to Education Northwest, a Portland-based organization that applies research-based solutions to the challenges of schools and communities.

It's a truth known nationwide. Christina Collins, on the communications team of the Massachusetts-based nonprofit Screening for Mental Health Inc. heralds an easily launched, cost-effective program called SOS Signs of Suicide, with separate programs tailored for middle school and high school students. The centerpiece is a DVD for students that reveals signs of depression and encourages getting help. The message of SOS is that depression is a treatable illness and teens can learn skills to respond to a potential suicide in a friend or family member using the ACT approach: Acknowledge, Care, and Tell.

An old-age issue

While there's a tendency to focus on youths, with suicide prevention efforts, it's important not to forget that in the United States, the elderly have one of the highest suicide rates, especially elderly white men. A decade ago, older people made up 13 percent of the population, but accounted for 19 percent of the completed suicides, said a study of suicide among the elderly published by researchers at the University of Pittsburgh School of Medicine in the journal Clinical Neuroscience Research. It's a little confusing because the attempt rate is higher among youths, but the elderly are more likely to complete a suicide. That trend hasn't changed.

They are not without resources, but some don't avail themselves. Studies found half of suicide victims 80 and older saw their general practitioner in the month before death, 26 percent the week before death and 7 percent the day before. The consultations were, at last half the time, solely for physical complaints.